Case Report: Over-the-Counter Codeine Use in a Senior Adult

By: Dr. Sara Meyer, BCPS

An 84-year-old female patient with a cough unresponsive to dextromethorphan went to her local pharmacy to seek relief. After describing her symptoms to the pharmacist, it was recommended she try a cough syrup containing guaifenesin and codeine. In North Carolina, pharmacists can dispense a small quantity of cough syrup containing codeine over the counter. Because this medication does not require a prescription, this information is not logged into the prescription drug monitoring program (PDMP), which may contribute to providers being unaware of their patients’ use of codeine. About ten days later, a family member called the patient’s primary care provider concerned the patient was experiencing increased drowsiness and confusion, and communicated the cough syrup use. The patient was also taking cyclobenzaprine and taking both the dextromethorphan cough syrup and codeine/guaifenesin cough syrup. These medications taken in combination likely contributed to the patient’s adverse symptoms.

Codeine is a natural opioid with a long history of use in cough. However, studies for this indication show it is no more effective than a placebo (1,2); moreover, it has been shown to cause dangerous adverse effects, including confusion, respiratory depression, and even death, especially in pediatric and elderly patients. (3,4,5,6) Despite this, when dispensed in cough preparations containing less than 200 milligrams of codeine/100mL or per 100 gm, a prescription is not required, making it fairly accessible to the general public. (7)

Recommendations for safe practice:

1. Always assess patients’ medications for concomitant central nervous system depressants (prescription or over-the-counter) or controlled substances, including a review of the PDMP.

2. Always provide important counseling points such as:

a. Possible side effects can include confusion, drowsiness, and even respiratory depression, especially in combination with certain other medications.

b. Notify the physician of any medications they take over the counter. c. Avoid alcohol (including overthe-counter drugs) while using codeine-containing cough preparations.

3. Consider dispensing naloxone if the patient is on concomitant CNS depressant(s) or has a history of medical conditions increasing the risk of overdose.

Author: Sara Meyer, PharmD, BCPS, is a Medication Safety Specialist and Opioid Stewardship Champion at Novant Health. SRG024@novanthealth.org

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Open Respiratory Research 2016;3:e000137. doi: 10.1136/ bmjresp-2016-000137 2. Bolser DC, Davenport PW. Codeine and cough: an ineffective gold standard. Curr Opin Allergy Clin Immunol. 2007;7(1):32-36. doi:10.1097/

ACI.0b013e3280115145 3. Friedrichsdorf SJ, Nugent AP,

Strobl AQ. Codeine-associated pediatric deaths despite using recommended dosing guidelines: three case reports. J Opioid Manag. 2013;9(2):151-155. doi:10.5055/ jom.2013.0156 4. Racoosin, JA, Roberson, DW,

Pacanowski, MA, Nielsen, DR.

New evidence about an old drug—risk with codeine after adenotonsillectomy. N Engl J Med. 2013;368(23):2155-2157. 5. Roxburgh A, Hall WD, Burns L, et al. Trends and characteristics of accidental and intentional codeine overdose deaths in Australia.

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